Prospective Utah Dental providers must submit:
- Guardian Credentialing Application
- Be sure to complete all fields or use N/A when necessary
- Disclosure of Ownership (DOO)* - Must be signed by an owner
- Be sure to complete all fields or use N/A when necessary
- W-9* (IRS version 2014 or later) - Must be signed by an owner
Including current copies of the applicant’s:
- Dental License
- DEA (or DEA waiver letter if necessary)
- Malpractice Insurance Certificate
- Specialty Certificate – if applicable
Important Information:
-
Please allow 30-60 days for the credentialing process.
-
Providers will be considered out of network until approved by our Credentialing Committee.)
To avoid delays in the credentialing process:
-
Please make sure all fields are completed, with no blank spaces. Use N/A where necessary.
-
Make sure all documents are NOT expired - and allow more than 60 days until expiration.
-
Applications with missing pages or incomplete information will be delayed or closed
Credentialing
Once we receive the completed application and required documents, it is submitted to the Guardian Credentialing Committee for review. Upon approval, the provider will receive a welcome letter and information about our program in general and our specific plans. Upon becoming an active participant in our Provider Network you can download our Provider Manual at any time by logging into the provider online portal.
Non-credentialed providers may not treat Premier Access members until their credentialing application is approved. Premier Access is not responsible for unpaid claims when members are treated prior to credentialing approval.
Missing, expired or incomplete documents will cause delayed processing or may cause file to deny or close prior to approval. Follow instructions closely. Use N/A where needed.
The credentialing process typically takes 30-60 days to complete.
Re-credentialing
Every three years, providers must submit an updated application, attestation, and current credentialing documents. The provider’s performance will be evaluated, with a review of any quality of care complaints.
A Complete Premier Access Re-credentialing application includes:
- Guardian Credentialing Application
- Be sure to complete all fields or use N/A when necessary
- Disclosure of Ownership (DOO)* - Must be signed by an owner
- Be sure to complete all fields or use N/A when necessary
- W-9* (IRS version 2014 or later) - Must be signed by an owner
Including current copies of the applicant’s:
- Dental License
- DEA (or DEA waiver letter if necessary)
- Malpractice Insurance Certificate
- Specialty Certificate – if applicable
Important Information:
-
Please allow 30-60 days for the credentialing process.
-
Providers will be considered out of network until approved by our Credentialing Committee.)
To avoid delays in the credentialing process:
-
Please make sure all fields are completed, with no blank spaces. Use N/A where necessary.
-
Make sure all documents are NOT expired - and allow more than 60 days until expiration.
-
Applications with missing pages or incomplete information will be delayed or closed
Provider Credentialing Forms
Re-credentialing Applications